Found in Translation

Network, Summer/Fall 2004

Parveen’s husband kicked her out of the family home in the middle of the night. A new immigrant to Canada from Pakistan, Parveen (not her real name) was suffering the effects of trauma from her abusive husband as well as the symptoms of schizophrenia. “She didn’t have any supports, she had nowhere to go,” says Gulshan Allibhai, coordinator of cross-cultural initiatives at the Canadian Mental Health Association (CMHA), Toronto Branch. “She ended up on the streets, she ended up homeless.”

Speaking only Urdu, Parveen still managed to find her way to a homeless shelter. The staff there connected her with the South Asian Women’s Centre, a settlement agency run for and by South Asian women. As a result of a new cross-cultural program led by CMHA Toronto, the women’s centre can afford a part-time mental health worker on staff. The worker was able to offer support to Parveen in her own language and connect her with other services.

“Without this project,” Allibhai says, “Parveen wouldn’t have been able to get the extra mental health support that she needed.”

The Culturally Competent Mental Health Project was created to improve access to mental health services by placing mental health workers in each of three settlement agencies serving immigrants and refugees. Funded by the New Trillium Foundation, with additional money from the United Way of Greater Toronto, the project is a partnership among CMHA Toronto, Community Resources Consultants of Toronto, the Afghan Women’s Counselling and Integration Community Support Organization, Polycultural Immigrant and Community Services, and the South Asian Women’s Centre.

This project, and similar work taking place around the province, was inspired by the growing cultural, racial, religious, and ethnic diversity of Ontario’s cities and communities. Mental health providers are changing and growing to meet the need for “culturally competent” mainstream services where professionals recognize and can respond to the specific challenges faced by newcomers and ethnoracial communities.

Although most newcomers successfully establish new lives in Canada, many face significant obstacles that have an impact on their mental health. Some have survived traumatic events, including war, civil unrest, or torture. Others face resettlement stress as a result of losing their former economic and social status, encountering racism, or having no access to community supports.

The CMHA Toronto project is a three-year initiative, begun in November 2003. It follows on the heels of two other successful partnerships with settlement agencies, Building Bridges and Breaking Barriers. In these previous health promotion projects, the groups collaborated to create a variety of educational materials about mental health and mental illness. Brochures, workshops, newspaper articles, radio broadcasts, and theatre performances were produced in Farsi, Greek, Hindi, Polish, Tamil, Urdu and other languages. According to Allibhai, this outreach led the partners into taking the next step together. “Now that we’ve done all the mental health promotion, and we have people who have mental illness learning about this,” she explains, the question became, “What are we going to do now?”

Toronto is one of the most multicultural cities in the world, with immigrants from over 160 countries. The current project focuses on the Afghani, Pakistani and former Yugoslavian communities. “The settlement agencies,” explains Allibhai, “identified these three as needing a lot of mental health services due to political unrest, resettlement stress, and trauma issues.”

The settlement agencies already offer practical resources to newcomers from these communities, including English-as-a-second-language classes, help in finding work and housing, and social support. But they don’t have the funding or the resources to provide more in-depth counselling or mental health services to their clients, and they face barriers in referring people to mainstream mental health services. Some newcomers won’t go to a mental health agency because of the stigma associated with mental health problems. Another barrier is the lack of mental health staff who speak the client’s language or who understand the specific mental health problems faced by newcomers.

“What this project does,” says Allibhai, “is offer [settlement agencies] a position of a mental health worker who can support people who are going through resettlement stress.” The workers provide supportive counselling to newcomers in their own language. They also refer people to other services including housing, support for women leaving abusive situations, and social and community programs.

“The biggest difficulty is the language barrier,” says Bora Todorovic. He puts in 15 hours a week as the mental health worker at Polycultural Immigrant and Community Services, serving the communities of the former Yugoslavia. One of the resources he can offer people is a list he has compiled of over 20 psychiatrists in Toronto who speak Serbian, Croatian or Bosnian.

All three mental health workers are members of the communities they work with, and they speak the same language. For Allibhai, this “negates the linguistic barriers” and “breaks down some of the cultural barriers because people are being helped by someone who may understand their worldview around mental illness.”

Steve Lurie, executive director of CMHA Toronto, believes it’s important to provide equal access to services for communities whose concept of mental illness may differ from the traditional Western understanding. “Every community identifies behavioural issues that stem from some definition of mental illness, whether it’s a spiritual definition or a clinical definition,” he explains. “[But] at some point, people say, ‘We need help, and we may try the indigenous assistance within our community or we may go to the local hospital or CMHA.’”

One of the key barriers for newcomers who have a serious mental illness is the difficulty of navigating a complicated and fragmented mental health system. At the point where they need to connect with mainstream mental health services, “the mental health worker is their link to services here at CMHA,” says Allibhai. The mental health worker can provide language assistance and help other mental health professionals understand their clients’ cultural needs and mental health issues. “The mental health worker can stay in the loop and be an advocate, so that people aren’t falling through the gap.”

Raising awareness within their communities is a key part of the job. “To educate people about mental health, that’s my main purpose,” declares Subuhi Jaffrey, the mental health worker at the South Asian Women’s Centre. “It can be very difficult to convince them, to bring them out of their shell,” she says. Jaffrey feels that stigma plays a role in people’s unwillingness to seek out help, as “mental health means something wrong to them, such as abuse.” As well, people may have their own coping skills and may not feel they need professional help. “They self-treat, using things like homeopathic treatment.”

Similarly, immigrants from the former Yugoslavia are “hesitant to ask for help,” says Todorovic. The people he serves have significant mental health issues related to the impact of war and civil unrest in their homeland. They are often described as an “orphan community” by mental health and settlement professionals, as so few services are directed to them, despite the evident need.

The three mental health workers don’t simply wait for people to find them. Instead, they use a variety of strategies to reach out to their communities. Jaffrey, who is Muslim, has introduced herself and the project to imams at mosques and other community leaders. “It can be a difficult thing to reach people in the Muslim community,” she says. “Ladies, in particular, feel ashamed.” Imans often provide counselling and support, and she encourages them to consider referring people to her by explaining that different people can play different roles in supporting people with mental health problems — “the imam in the mosque, the psychiatrist in the hospital, and the mental health worker in the community.”

Todorovic uses a variety of media to reach people. He runs ads and writes articles in local ethnic-language newspapers about mental health issues and how the project can help. He will also appear in the fall on a cable television show geared to viewers from the former Yugoslavia.

Both Jaffrey and Todorovic stress the importance of the personal connections they make with people. Jaffrey describes her experience with one woman who was referred to her from a local hospital. She was told that the woman “doesn’t like to talk,” but Jaffrey visited the woman at home, made a personal connection, and the woman opened up to her. Todorovic, who trained in the former Yugoslavia as a medical doctor and then learned to speak English after arriving in Canada two years ago, feels that his own experience as an immigrant helps him to connect with his clients, so that their fear of getting help for mental health problems is overcome.

Despite the fact that funding for staff time is limited and getting word about the project out to different communities can be challenging, Allibhai says they were “shocked” that so many people accessed their services within the first year of starting the program. Each of the three mental health workers is now supporting from 10 to 36 clients.

Golali Nawabi is the only full-time mental health worker with the project. She works with women and men from the Afghani community at the Afghan Women’s Counselling and Integration Community Support Organization. She works in partnership with the other mental health agency in the project, Community Resources Consultants of Toronto. The success of her work, and the need for her services, is shown by the fact that she now has 36 people on her caseload and has had to start a waiting list.

CMHA Toronto’s Culturally Competent Mental Health Project is only one of several outreach activities in the mental health community attempting to meet that demand. The Mood Disorders Association of Ontario has recently begun to partner with agencies that serve ethnocultural communities in the Greater Toronto Area to promote their self-help groups and other programs. They also offer training to help ethnocultural agencies develop their own self-help groups.

Recognizing and valuing diversity has become a priority for the Centre for Addiction and Mental Health (CAMH), a large public hospital located in Toronto, with community offices throughout the province. Their Building Bridges Breaking Barriers project is a joint initiative with five ethnoracial and cultural agencies, designed to ensure that members of those communities have full access to mental health and addiction services at CAMH. Recommendations from participants in the program have now been incorporated into day-to-day services, with plans to expand the project into other communities and programs within the Centre.

The goal of many of these projects is to change the way mental health organizations offer support and services. CMHA Toronto has been engaged in the process of organizational change since the late 1970s, when they began reaching out to specific ethnocultural and racial communities. Today, CMHA Toronto offers a wide range of culturally competent programs, including specialized case management services for people with serious mental illness from the Tamil and Somali communities and for French and Italian speakers. Lurie and Allibhai view their work as an ongoing learning experience. Says Lurie, “You have to be constantly asking within the organization, ‘How do we ensure that we’re sensitive to the issues of diversity and culture?’”

“Our staff need to be at a level where they’re going to be able to understand and assess for migration stress and trauma issues, to look for the experiences refugees and immigrants have gone through,” says Allibhai. She trains CMHA staff and other professionals to use culturally sensitive mental health assessment tools. According to the definition developed by educators for the Building Bridges project, “the culturally competent helper understands that newcomers face challenges in adjusting culturally, linguistically and economically to Canada.”

Comparing today’s mental health services with what little existed when she and her family came to Canada as refugees from Uganda in 1972, Allibhai remarks, “At least we have some now. But if you look at the span of things, that’s 32 years ago, and we’ve maybe moved inches.”

Both Lurie and Allibhai stress the need to continue pushing on both fronts — to increase the cultural competence of all staff working within mental health agencies, and to build partnerships with ethnoracial community groups to increase their capacity to offer support and referrals. “Maybe because of the concern of confidentiality, maybe [because] it’s a smaller community where everybody knows everybody,” says Allibhai, some people prefer to visit a CMHA. Other members of the community, she continues, “only want to go to a language- or culture-specific agency, so you have to give people that choice.”

Toronto has been called the “world within a city.” According to city officials, people from 169 countries have made Toronto their home. Almost half of these newcomers, 43 percent, arrived in Canada since 1991. In 2001, the largest number of immigrants to Toronto came from China, India, Pakistan, Philippines and Sri Lanka. In the home, 29 percent of Torontonians speak a language other than English or French.

Numbers, however, only tell part of the story. People’s mental health is shaped by many factors, including economic, social and political status. Ethnocultural and newcomer communities are often marginalized, without access to adequate housing, income, employment, and education, all of which are recognized as key determinants of health. Education and employment skills gained in their home country may not be formally recognized in Canada, so that many people end up in low-paying jobs that don’t reflect their training.

Lack of employment opportunities contributes to high rates of poverty. More than 34 percent of non-European ethnoracial families in Toronto live in poverty, at least twice the rate for European and Canadian-born people. Despite the fact that visible “minorities” make up almost 43 percent of Toronto’s population, many are still confronted by racism and discrimination in housing, education, employment and other important areas of life, often with a negative impact on their mental health.